Comparison between stylet and bougie with the C-MAC D-blade in cervical simulated immobility. A prospective randomized controlled trial

Introduction The C-MAC D-blade was designed for difficult airway intubation scenarios. To facilítate easier and faster endotracheal intubation in the laryngoscopy paradox, an introducer is preferred. Hence, we decided to conduct a study to compare the 60° angled C-MAC stylet and the gum elastic bougie as aids to intubation while using the C-MAC D-blade laryngoscope in a simulated difficult airway setting. Objective To compare the ease of oral intubation with the use of the C-MAC stylet (60° angled stylet) versus intubation performed over a bougie inserted using the C-MAC D-blade guidance in patients with simulated restricted cervical mobility. Method Prospective, randomized controlled single-center study. Intubation using the C-MAC D-blade laryngoscope was performed in 48 surgical patients randomly assigned to 2 groups of 24 each: Stylet group, Group S (using 60° angled stylet) and Bougie group, Group B (using bougie) after providing manual in-line stabilization to restrict cervical mobility. The Mann-Whitney U test and the Chi square test were used as applicable. Results The use of stylet resulted in easier (Group S 75% vs. Group B 16.7%) and faster (Group S 26.83 ± 8.61s vs. Group B 47.18 ± 16.46s) intubation with fewer attempts compared to group B. Both groups experienced a similar hemodynamic stress response to intubation. Conclusions The 60° angled C-MAC Stylet is a more effective and time-saving intubation aid with C-MAC D-blade compared to bougie.

Introducción: El videolaringoscopio C-MAC D-blade se diseñó para los casos de intubación de la vía aérea difícil. Para facilitar una intubación más rápida y sencilla en la paradoja de la laringoscopía se prefiere un introductor. Por tanto, decidimos realizar un estudio para comparar el estilete de 60° C-MAC y el bougie elástico de goma como ayudas para la intubación utilizando el laringoscopio C-MAC D-blade en una situación simulada de vía aérea difícil. Objetivo: Comparar la facilidad de intubación oral mediante el uso del estilete del C-MAC (estilete angulado de 60°) con la intubación realizada sobre un bougie insertado con la guía del C-MAC D0-blade en pacientes con restricción simulada de la movilidad cervical. Métodos: Estudio prospectivo, aleatorizado y controlado realizado en un solo centro. Se realizó intubación utilizando el laringoscopio C-MAC D-blade D en 48 pacientes quirúrgicos asignados aleatoriamente a 2 grupos de 24 cada uno: grupo de estilete, grupo S (con el estilete angulado de 60°) y el grupo de bougie o grupo B (con bougie) después de establecer una estabilización manual del eje para restringir la movilidad cervical. Se aplicaron las pruebas U de Mann-Whitney U y de Chi cuadrado según correspondiera. Resultados: Con el estilete fue más fácil (Grupo S 75% vs. Grupo B 16.7%) y más rápida (Grupo S 26.83 ± 8.61s vs. Grupo B 47.18 ± 16.46s) la intubación, requiriéndose un menor número de intentos en comparación con el Grupo B. Los dos grupos experimentaron un estrés hemodinámico similar en respuesta a la intubación. Conclusiones: El estilete angulado de 60° C-MAC es una ayuda más efectiva y ahorra más tiempo con el C-MAC D-blade en comparación con el bougie.

Anesthetic induction and endotracheal intubation in the sitting position due to the fixed forearm caught by a meat grinder

Abstract A male patient was scheduled for urgent amputation of his right forearm. His right forearm was stuck inside the insertion slot of a meat grinder, resulting in severe pain to his injured arm. His upper body could not move to sit in a semi-upright position. An endotracheal tube was successfully placed after rapid sequence intubation using a video laryngoscope from behind the patient on the first attempt. This case report is the first documentation of successful anesthetic induction with subsequent endotracheal intubation using a video laryngoscope from behind an injured patient whose upper body was upright with limited positioning.

Anesthetic induction and endotracheal intubation in the sitting position due to the fixed forearm caught by a meat grinder.

A male patient was scheduled for urgent amputation of his right forearm. His right forearm was stuck inside the insertion slot of a meat grinder, resulting in severe pain to his injured arm. His upper body could not move to sit in a semi-upright position. An endotracheal tube was successfully placed after rapid sequence intubation using a video laryngoscope from behind the patient on the first attempt. This case report is the first documentation of successful anesthetic induction with subsequent endotracheal intubation using a video laryngoscope from behind an injured patient whose upper body was upright with limited positioning.

Laringoscopio híbrido: Una opción de costo razonable para el abordaje de la vía aérea difícil. Reporte de un caso / Hybrid laryngoscope: A reasonable option cost for approaching the airway difficulty. A case report

The laryngoscope is a primary tool that every medical professional who performs in airway care should know how to use. Although it's an irreplaceable tool, in the last decade have been considered transformations and modifications in them that have allowed the medical professional, especially the anesthesiologist to perform successfully for critical management especially in the context of unanticipated difficult airway, because most of the time the only available resource at hand is the laryngoscope and a malleable stylet that guides the orotracheal. The new technological age of visual instruments such as video cameras and photographs many of these with small sizes, has been used in the manufacture of video laryngoscopes that today are used, which have managed to approach the aerea in a minimally traumatic way and also safeguard lives. Our hydrid video laryngoscope is a handcrafted tool made of high-quality elements, strength, durability and low cost.

El laringoscopio es una herramienta primordial que todo profesional médico que se desempeña en la atención de la vía aérea debería saber utilizar. Pese a ser un dispositivo insustituible, en la última década se han considerado transformaciones y modificaciones en los mismos que le han permitido al profesional de la medicina, fundamentalmente al anestesiólogo, desempeñarse exitosamente durante el manejo crítico especialmente en el contexto de vía aérea difícil no anticipada, en el que la mayoría de las veces el único recurso disponible a la mano es el laringoscopio y un estilete maleable que sirve de guía para dirigir la sonda orotraqueal. La nueva era tecnológica de los instrumentos visuales como cámaras de video y fotografía, (muchos de estos con tamaños reducidos) han sido empleados en la fabricación de videolaringoscopios que hoy en día se utilizan y que han logrado abordar la vía aérea de manera mínimamente traumática, así mismo, salvaguardar vidas. Nuestro videolaringoscopio híbrido es una herramienta artesanal fabricada con elementos de alta calidad, resistencia, durabilidad y bajo costo.

Anestesia en paciente pediátrico con Síndrome de Treacher Collins / Anesthesia in a pediatric patient withTreacher Collins Syndrome / Anestesia em paciente pediátrico com Síndrome de Treacher Collins

El Síndrome de Treacher Collins (STC) constituye un reto para el anestesiólogo por malformaciones craneofaciales que complican el manejo de su vía aérea e intubación. Presentamos el caso de una paciente (8 años) con diagnóstico de STC que debía someterse a una cirugía de colocación de implante de conducción ósea bajo anestesia general. Presentaba un antecedente de intubación difícil, marcada micrognatia y distancia tiromentoniana de 2 cm. Se planteó un esquema de intubación en dos etapas secuenciales. En la primera etapa se realizó una evaluación de la vía aérea (visualización de la glotis) bajo sedación con dexmedetomidina, remifentanilo y propofol. Al visualizar la glotis se pasó a la segunda etapa para realizar la intubación posterior a la inducción anestésica.El manejo exitoso se fundamentó en una sedación adecuada y la utilización de un videolaringoscopio con pala curva para la evaluación previa de la vía aérea y posterior intubación sin complicaciones

Treacher Collins Syndrome (TCS) constitutes a challenge for the anesthesiologist due to craniofacial malformations that make management of the airway and intubation difficult. We present a case of a patient (8-year-old) diagnosed with TCS who had to undergo surgery for the placement of a bone conduction implant under general anesthesia. She had a history of difficult intubation, marked micrognathia and a thyromental distance of 2 cm. An intubation scheme in two sequential stages was proposed. In the first stage, an evaluation of the airway (visualization of the glottis) was carried out under sedation with dexmedetomidine, remifentanil and propofol. When the glottis was visualized, we proceeded to the second stage to carry out intubation after anesthetic induction.The successful management of this case was based on adequate sedation and the use of a video laryngoscope with a curved blade for prior evaluation of the airway and subsequent intubation without complications

A síndrome de Treacher Collins (STC) constitui um desafio para o anestesiologista devido às malformações craniofaciais que dificultam o manejo da via aérea e a intubação. Apresentamos o caso de uma paciente (8 anos) com diagnóstico de STC que foi submetida a uma cirurgia para colocação de implante de condução óssea sob anestesia geral. Ela tinha história de intubação difícil, micrognatia acentuada e distância tiromentoniana de 2 cm. Foi proposto um esquema de intubação em duas etapas sequenciais. Na primeira etapa, foi realizada avaliação das vias aéreas (visualização da glote) sob sedação com dexmedetomidina, remifentanil e propofol. Quando a glote foi visualizada, a segunda etapa foi realizada para realização da intubação após a indução anestésica. O manejo bem-sucedido baseou-se na sedação adequada e no uso de videolaringoscópio com lâmina curva para avaliação prévia da via aérea e posterior intubação sem complicações

Anestesia en paciente pediátrico con Síndrome de Treacher Collins / Anesthesia in pediatric patient with Treacher Collins Syndrome

El Síndrome de Treacher Collins (STC) constituye un reto para el anestesiólogo por malformaciones craneofaciales que complican el manejo de su vía aérea e intubación. Presentamos el caso de una paciente (8 años) con diagnóstico de STC que debía someterse a una cirugía de colocación de implante de conducción ósea bajo anestesia general. Presentaba un antecedente de intubación difícil, marcada micrognatia y distancia tiromentoniana de 2 cm. Se planteó un esquema de intubación en dos etapas secuenciales. En la primera etapa se realizó una evaluación de la vía aérea (visualización de la glotis) bajo sedación con dexmedetomidina, remifentanilo y propofol. Al visualizar la glotis se pasó a la segunda etapa para realizar la intubación posterior a la inducción anestésica. El manejo exitoso se fundamentó en una sedación adecuada y la utilización de un videolaringoscopio con pala curva para la evaluación previa de la vía aérea y posterior intubación sin complicaciones.

Treacher Collins Syndrome (TCS) constitutes a challenge for the anesthesiologist due to craniofacial malformations that make management of the airway and intubation difficult. We present a case of a patient (8-year-old) diagnosed with TCS who had to undergo surgery for the placement of a bone conduction implant under general anesthesia. She had a history of difficult intubation, marked micrognathia and a thyromental distance of 2 cm. An intubation scheme in two sequential stages was proposed. In the first stage, an evaluation of the airway (visualization of the glottis) was carried out under sedation with dexmedetomidine, remifentanil and propofol. When the glottis was visualized, we proceeded to the second stage to carry out intubation after anesthetic induction. The successful management of this case was based on adequate sedation and the use of a video laryngoscope with a curved blade for prior evaluation of the airway and subsequent intubation without complications.

Comparison of different methods of nasogastric tube insertion in anesthetized and intubated patients / Comparação de diferentes métodos de inserção de sonda nasogástrica em pacientes anestesiados e intubados

Abstract Background Nasogastric tube insertion may be difficult in anesthetized and intubated patients with head in the neutral position. Several techniques are available for the successful insertion of nasogastric tube. The primary aim of this study was to investigate the difference in the first attempt success rate of different techniques for insertion of nasogastric tube. Secondary aim was to investigate the difference of the duration of insertion using the selected technique, complications during insertion such as kinking and mucosal bleeding. Material and methods 200 adult patients, who received general anesthesia for elective abdominal surgeries that required nasogastric tube insertion, were randomized into four groups: Conventional group (Group C), head in the lateral position group (Group L), endotracheal tube assisted group (Group ET) and McGrath video laryngoscope group (Group MG). Success rates, duration of insertion and complications were noted. Results Success rates of nasogastric tube insertion in first attempt and overall were lower in Group C than Group ET and Group MG. Mean duration and total time for successful insertion of NG tube in first attempt were significantly longer in Group ET. Kinking was higher in Group C. Mucosal bleeding was statistically lower in Group MG. Conclusion Use of video laryngoscope and endotracheal tube assistance during NG tube insertion compared with conventional technique increase the success rate and reduce the kinking in anesthetized and intubated adult patients. Use of video laryngoscope during nasogastric tube insertion compared to other techniques reduces the mucosal bleeding in anesthetized and intubated adult patients.

Resumo Justificativa A inserção de sonda nasogástrica (NG) pode ser difícil em pacientes anestesiados e intubados com a cabeça em posição neutra. Há várias técnicas para a inserção bem-sucedida de sonda NG. O objetivo primário deste estudo foi investigar a diferença da taxa de sucesso na primeira tentativa de diferentes técnicas para inserção de sonda NG. O objetivo secundário foi investigar a diferença do tempo de inserção com o uso da técnica selecionada e as complicações durante a inserção (dobradura da sonda e sangramento da mucosa). Material e métodos 200 pacientes adultos que receberam anestesia geral para cirurgias abdominais eletivas que exigiam inserção de sonda NG foram randomicamente distribuídos em quatro grupos: grupo convencional (Grupo C), grupo com a cabeça posicionada lateralmente (Grupo L), grupo com assistência de tubo traqueal (Grupo TE) e grupo com videolaringoscópio McGrath (grupo MG). As taxas de sucesso, os tempos de inserção e as complicações foram registrados. Resultados As taxas de sucesso de inserção da sonda NG na primeira tentativa e em geral foram menores no Grupo C do que nos grupos TE e MG. As durações e os tempos totais de inserção bem-sucedida da sonda NG na primeira tentativa foram significativamente maiores no Grupo TE. Dobradura foi maior no Grupo C. Sangramento da mucosa foi estatisticamente menor no Grupo MG. Conclusão O uso de videolaringoscópio e de TE durante a inserção de sonda NG comparado com o uso da técnica convencional aumentou a taxa de sucesso e reduziu a dobradura da sonda em pacientes adultos anestesiados e intubados. O uso de videolaringoscópio durante a inserção de sonda NG em comparação com outras técnicas reduz o sangramento da mucosa em pacientes adultos anestesiados e intubados.

[Comparison of different methods of nasogastric tube insertion in anesthetized and intubated patients]. / Comparação de diferentes métodos de inserção de sonda nasogástrica em pacientes anestesiados e intubados.

BACKGROUND: Nasogastric tube insertion may be difficult in anesthetized and intubated patients with head in the neutral position. Several techniques are available for the successful insertion of nasogastric tube. The primary aim of this study was to investigate the difference in the first attempt success rate of different techniques for insertion of nasogastric tube. Secondary aim was to investigate the difference of the duration of insertion using the selected technique, complications during insertion such as kinking and mucosal bleeding. MATERIAL AND METHODS: 200 adult patients, who received general anesthesia for elective abdominal surgeries that required nasogastric tube insertion, were randomized into four groups: Conventional group (Group C), head in the lateral position group (Group L), endotracheal tube assisted group (Group ET) and McGrath video laryngoscope group (Group MG). Success rates, duration of insertion and complications were noted. RESULTS: Success rates of nasogastric tube insertion in first attempt and overall were lower in Group C than Group ET and Group MG. Mean duration and total time for successful insertion of NG tube in first attempt were significantly longer in Group ET. Kinking was higher in Group C. Mucosal bleeding was statistically lower in Group MG. CONCLUSION: Use of video laryngoscope and endotracheal tube assistance during NG tube insertion compared with conventional technique increase the success rate and reduce the kinking in anesthetized and intubated adult patients. Use of video laryngoscope during nasogastric tube insertion compared to other techniques reduces the mucosal bleeding in anesthetized and intubated adult patients.

Intubación nasotraqueal con ‘videolaringoscopio artesanal’ en paciente con vía aérea dificultosa prevista

RESUMEN El objetivo de este trabajo fue analizar un caso de vía aérea dificultosa prevista que requirió intubación nasotraqueal (INT) para cirugía maxilofacial, y se resolvió con un laringoscopio convencional modificado mediante el agregado de una mini cámara. Paciente de sexo femenino de 68 años, coordinada para osteosíntesis de maxilar inferior y órbita con INT. Antecedentes: neoplasma de mama operado. Fumadora intensa. Traumatismo encéfalocraneano 3 semanas antes, con fractura de peñasco y sin lesiones parenquimatosas. Parálisis facial periférica secundaria al trauma. Del examen se destaca: desviación de rasgos a izquierda, parálisis de Bell, apertura bucal disminuida (2,5 cm), Mallampati IV, flexo-extensión de cuello limitada, distancias conservadas. Se preparó la narina derecha con solución de adrenalina aplicada con torundas. Premedicación con Fentanil 2 mg/kg, preoxigenación al 100%, inducción con propofol. Se comprobó una buena permeabilidad de la narina derecha digitalmente, por lo que se pasó una sonda endotraqueal (SET) 7.0 hasta atravesar los cornetes; laringoscopía con pala curva número 3 preparada con una cámara de 7 mm (7 mm USB Endoscope, Welsky Technologies Limited) pegada en el extremo distal, conectada a una notebook en la cual se visualizaron las estructuras. No se administró relajante muscular hasta lograr la intubación. Al visualizar las cuerdas vocales en la pantalla, se progresó la SET en la vía aérea sin necesidad de utilizar pinza de Magill. Conclusión: el laringoscopio modificado con el agregado de una cámara y bajo visión en una pantalla fue efectivo para realizar la INT y resolver esta situación de vía aérea dificultosa prevista.

SUMMARY The objective of this work was to analyze a case of expected difficult airway that required nasotracheal intubation (INT) for maxillofacial surgery, which was resolved with a traditional laryngoscope modified by the addition of a mini-camera. Female patient, 68 years of age, scheduled for osteosynthesis of jaw and orbit with INT. History: operation of breast cancer. Heavy smoker. Traumatic brain injury 3 weeks before, with petrous bone fracture and no parenchymal injuries. Peripheral facial paralysis secondary to trauma. Examination shows: features deviation to the left, Bell's palsy, reduced mouth opening (2.5 cm), Mallampati IV, limited flexion and extension of the neck, distances are preserved. Right nostril was prepared with adrenaline solution applied with swabs. Premedication with Fentanyl 2 g/kg, preoxygenation at 100%, induction with propofol. Good permeability of right nostril was confirmed by digital examination, allowing to insert a 7.0 endotracheal tube (ETT) until passing through the turbinate bones; laryngoscopy with #3 curved blade equipped with a 7 mm camera (7 mm USB Endoscope, Welsky Technologies Limited) at the distal tip, connected to a notebook wherein structures were visualized. No muscle relaxant was administered until intubation was completed. ETT was introduced after visualizing the vocal cords on the screen; Magill forceps were not used. Conclusion: the laryngoscope modified by the addition of a camera for visualization on a monitor screen was effective to carry out INT and manage this expected difficult airway situation.

RESUMO O objetivo deste trabalho foi analisar um caso de previsão de via aérea difícil que requereu intubacão nasotraqueal (INT) para cirurgia maxilofacial, que foi solucionado com um laringoscópio convencional modificado mediante o acoplamento de uma câmera. Paciente do sexo feminino de 68 anos, marcada para realizar osteossintese do maxilar inferior e orbita com INT. Antecedentes. Operada de neoplasia de mama. Tabagista intensa. Traumatismo encefalocrãniano há 3 semanas, com fratura de rochedo e sem lesões parenquimatosas. Paralisia facial periférica secundaria ao trauma. Do exame destaca-se : desvio de simetria facial a esquerda, paralisia de Bell, abertura bucal diminuída (2.5 cm) Mallampatti IV, flexo-extensão do pescoço limitada, distancias conservadas. Preparou-se a narina direita com solução de adrenalina aplicada em torundas. Premedicação com Fentanil 2 µg /kg, pré-oxigenacão a 100%, indução com Propofol. Comprovou-se boa permeabilidade da narina direita digitalmente, pela qual se introduziu uma sonda endotraqueal (SET) 7.0 até atravessar os cornetos , laringoscopia com lamina curva numero 3 preparada com uma câmera de 7 mm (7 mm USB Endoscope , Welsky Technologies Limited) acoplada ao extremo distal, conectada a um notebook no qual se visualizaram as estruturas. Não se administrou relaxante muscular ate que houve-se sucesso na intubação. Ao visualizar as cordas vocais na tela, se progrediu a SET na via aérea sem necessidade de utilização de pinça de Magill. Conclusão: o laringoscópio modificado com uma câmera acoplada e visualização numa tela foi efetivo para realizar a INT e resolver essa situação de previsão de via aérea difícil.